The gum elastic bougie, bougie introducer, tube introducer, or endotracheal tube introducer (hereinafter “bougie”) is a narrow diameter tracheal device that is the preferred adjunct device for intubation. It is critical and life saving that the introducer and endotracheal tube be introduced into the trachea rather than the esophagus. Although newer fiber optics and video laryngoscopes are available, their expense, complexity, lack of availability in every situation, and utility of the bougie means that the bougie is still widely used. In fact, the bougie is still used in conjunction with these newer devices. The bougie is often utilized where patients have anterior airways, airways obscured by blood or secretions, or limited neck mobility.
The bougie has a distal tip or coude tip that bends (e.g., at an angle of 35-40°) so as to assist the user in moving the distal tip into the trachea (or air passage) rather than down the esophagus. Since the trachea sits anterior to the esophagus, the device, if not carefully maneuvered, is more likely to enter the esophagus than the trachea. Ideally, positioning techniques can be used so that an emergency expert can visulize the glottic opening, or at least a part of the trachea, and guide the distal tip into the trachea. However, in some cases the glottic opening may not be visible or the angle too great to position the endotracheal tube. For instance, this may occur where the head cannot be tilted back, the patient has abnormal anatomy, the patient is pediatric age or there is obscuring blood and secretions. In such instances, bougie users must rely on feel and experience alone to guide the distal tip into the correct passage.
This procedure requires that proper depth of insertion and axial orientation of the distal tip be achieved. Depth should be sufficient for the distal tip to pass the vocal chords. Depth is typically gauged by measuring the bougie against the external anatomy of the patient and noting the needed depth. Once placed in the oropharanx, the operator also gauges depth by feeling “tracheal clicks” as the distal tip moves over ribs in the trachea. Since these ribs are only on an anterior 180° of the trachea, it is essential to keep the distal tip of the bougie pointed toward an anterior 180° of the trachea. However, every patient's anatomy is different and thus ‘feeling’ the orientation of the distal tip can be challenging and inconsistent. Alternatively, bougies occasionally have been produced with one or more visual depth indicators printed on them to assist in achieving proper depth of insertion. However, these indicators become difficult if not impossible to see in circumstances where liquids (e.g., blood) are present or where lighting is poor.
Furthermore, successfully passing the distal tip through the glottic opening as opposed to the esophagus is far more likely when the distal tip is bent toward or facing an anterior of the neck. Yet, once in the airway the distal tip is not visible, and because the shape is tubular and smooth there is little or no indication of the distal tips's orientation. Users are often forced to attempt to ‘feel’ the distal tip's orientation as it contacts known parts of the throat and trachea.
These inherent flaws in the traditional bougie, which can be life threatening, have been well known to users of the bougie for decades. Yet, the product has remained largely unchanged and without significant innovation in this regard. Medical textbooks do not discuss these challenges, and leadership in the medical field has further ignored these problems thus leaving it to bougie users to deal with these challenges in ways that are not ideal and that have endangered lives for many years.